Misha Friedman

Daniel Horn is a physician at Massachusetts General Hospital on a team charged with preparing the institution for an influx of coronavirus patients. Over the past few weeks, I’ve checked in with him periodically to get one doctor’s sense of how American health care has fared in the face of crisis. When I spoke with him on Friday afternoon, he told me he was growing concerned that the realities of income inequality were asserting themselves in the care for victims of the virus.

Franklin Foer: I’m aching for any shard of good news. So when you scan the horizon, is there anything short of bleakness that you see?

Daniel Horn: I think we’re going to see lots of pockets of bleakness, for sure. I do think that, here in Boston and at Mass General, we are maintaining hope that aggressive, comprehensive social distancing really may have made a difference. We do expect a major surge, undoubtedly. But collective social sacrifice around social distancing has bought us extra time to prepare, and I do believe that will save lives. We’ve had time to convert whole floors, in advance of what we anticipate to be a surge, to be coronavirus-only floors. We didn’t have to prepare on the fly.

Foer: But you work at one of America’s greatest, best-resourced hospitals …

Horn: I have to say I’m worried about our safety in our hospitals, in our community hospitals, which didn’t start getting ready for this as early as we did, and may not have as comprehensive a plan, nor the faculties to get it done.

You know, my dad is an anesthesiologist in Virginia, in a community hospital. My father called me, a primary-care doctor, to ask me to help get him our best anesthesia protocols for putting breathing tubes in patients, and how to do that safely. And I was able to, and it was marvelous to see what our anesthesiologists at Mass General had put together, but it was concerning to me that he needed to call me, a primary-care doctor, to try to get that help. That was an alarm for me.

Foer: That’s pretty troubling … I hadn’t considered that with a proliferation of ventilators, we’ll need people who know how to operate them.

Horn: Well, and what I expect we’ll see out of this is, a bunch of online rapid-training curricula will spring up. And I also think we’ll see major advances in remote intensive-care monitoring, which is something that exists in the country, but not in a large capacity. But it’s a very compelling idea, right? You can take a machine, and a reading that can be heavily surveilled with all kinds of vital signs monitoring, and video and communications technologies, and manage the machine from a remote location and on a large scale. Putting a breathing tube in a patient is a different question.

Foer: What’s the biggest difference between the have and have-not hospitals?

Horn: I think health care runs on a fairly slim margin, generally. Something on a 3 to 5 percent margin. And so, even though hospitals knew this was coming, it would be difficult for many hospitals to have a large outlay of capital to start stockpiling supplies, like $50,000 ventilators, in advance. And indeed, we’ve seen stories that early on, as word of ventilator shortages [was] blooming, we didn’t see a rapid uptake in ventilator ordering across the country. It’s not like many hospitals have this large cash reserve sitting around to make rapid investments.

Foer: If there was one thing that MGH was able to do in advance that you wish the rest of the country could have done, what is it?

Horn: One of the things we’ve been very fortunate to do is to adopt a mask-all-day policy for our health-care workers. When we walk in the hospital door now, there’s a security line set up with Cal Stat, which is our Purell. And then, we’ve laid out surgical masks on a table that you pick up. And you’re expected to wear the mask when you’re in a clinical setting. One mask, all day. Unless the mask gets soiled or damaged, in which case you change it. We’ve seen that in countries that have really protected their health-care workers, that was a successful strategy. I understand that there are profound mask shortages, and it’s a real travesty, and a real failure of leadership in our country, that not every hospital system will be able to implement a mask-all-day policy, like we have.

Foer: You mentioned profit margins. Are you having to think about that in the middle of the crisis?

Horn: We’re moving 70 percent of our routine care to visual-based platforms and phone-based platforms. And, in a moment where what we want is people to be inspired to just do the right thing—whether that’s a phone call or a video visit, or an email—we are still having to spend much more time than I would want talking to our compliance team, our billing team, our general counsel, about, “Will phone visits be paid at the same rate as video visits?” For some payers, we’re already hearing it won’t. They’re going to pay a video visit more approximate to an in-person visit. But a telephone call with a patient, with a medical record open that actually replicates care and leads to really meaningful conversations, the payers are like, “Yeah, that’s got to be paid out at a discounted rate,” in this moment is, to me, a very concerning thing.

More importantly, smart people in hospitals are having to spend their time leading us through this, in a moment of crisis, instead of focusing their talents elsewhere. It’s just an interesting moment to reflect on the fact that we don’t have universal health care. We don’t have what we call a model, where primary-care networks are paid to care for the population, in whatever way they need to.

Foer: It’s one of the insane paradoxes of modern medicine: It seems like hospitals will never have been so busy, yet the whole experience will deplete their revenue streams and actually make it so a bunch of doctors are going to get paid less money.

Horn: Like I said, my dad is an anesthesiologist in Virginia, in a community hospital, and they took a much longer time than we did to cancel elective surgeries. And the reason that they took a longer time to cancel elective surgeries, in my opinion, is because without the surgeries, they don’t get paid. And so, right now, when he’s not needed in the operating room because there are so few surgeries, he’s furloughed. I’m very grateful for that, because he’s an older physician, and I’m grateful that he’s not working. But again, that’s not a good safety net for our doctors. I know the rest of society is feeling very parallel things, and doctors are in very fortunate positions. But again, just an interesting reflection on our health-care system.

Oh, you asked about reasons for optimism. I have one inspirational thing.

Foer: Hit me.

Horn: I wrote an op-ed about how the U.S. could avoid Italy’s ventilator crisis. The phone number for my clinic had to get shut down for a day, after the piece, because people were so desperate to try to reach out to offer their ideas, that they were calling my patient-care line, and patients couldn’t get through. So that was not a good scene. But, what’s happening is—and it’s not my doing, by any stretch—but there’s a hackathon in Boston this weekend [to create a rapidly deployable mechanical ventilator within 90 days]. A virtual hackathon, that has over 1,000 participants, and is sponsored by numerous big tech companies and large corporations.

[That people and] large firms want to step up is really inspirational. But I would just simply say that at Mass General we were told, “We need four new clinics opened, to care for patients of respiratory illness, within two weeks. Get it done, and let us know what you need to get it done.” And that is not the way this ventilator crisis is being handled. And I think in retrospect, that will be seen as one of the major oversights in the history of managing disasters in our country.

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